In reporting the appropriate ICD-10-PCS codes, a coder must know what is included in the terminology of products of conception (POC). The POC include all components of pregnancy, including the fetus, embryo, amnion, umbilical cord, and the placenta.
Helpful Tidbits for Coding OB Procedures
Procedures performed on the products of conception are coded to the Obstetrics section
Procedures performed on the pregnant female other than the products of conception are coded to the appropriate root operation in the Medical and Surgical section
Curettage of the endometrium is coded in the Obstetrics section, to the root operation Extraction and the body part Products of Conception, Retained
Evacuation of retained products of conception is coded to the Obstetrics section, to the root operation Extraction and the body part Products of Conception, Retained
Pitocin administration given to induce labor should be coded separately
Pitocin administration given to augment active labor is NOT coded separately
Delivery of placenta only (baby delivered outside of hospital) is coded as delivery of products of conception since ICD-10-PCS does not differentiate between delivery of the baby and the placenta
Whenever there is assisted delivery, it should be coded
Peri-urethral laceration repair is coded as repair of vulva since peri-urethral is vulvar tissue
Vacuum assistance during cesarean section is not coded separately
When more than one location is documented to have an obstetric tear, code the deepest layer involved in the tear
Repair of second-degree perineal laceration occurring during vaginal delivery is coded as open approach since the laceration has cut through the external body layers exposing muscle (based on the definition of second-degree perineal laceration)
High vaginal wall lacerations are not seen/coded often
References ICD-10-CM/PCS Coding Clinic®, Fourth Quarter 2018 Page: 49-51 ICD-10-CM/PCS Coding Clinic®, Fourth Quarter 2013 Page: 120 ICD-10-CM/PCS Coding Clinic®, Second Quarter 2014 Page: 9 ICD-10-CM/PCS Coding Clinic®, Fourth Quarter 2014 Pages: 17-19 and 43-44 ICD-10-CM/PCS Coding Clinic®, Third Quarter 2017 Page: 5 ICD-10-CM/PCS Coding Clinic®, Second Quarter 2016 Page: 33-34 ICD-10-CM/PCS Coding Clinic®, First Quarter 2016 Page: 8 ICD-10-PCS Official Guidelines for Coding and Reporting FY 2019
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
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